How To Conduct A Successful Medical Audit?
A medical audit is conducted within a healthcare organization to review its performance successfully. So, how it can be conducted successfully?
The medical audit serves to be a vital part of a healthcare organization’s compliance plan as it greatly helps in identifying medical errors and taking remedial actions to eliminate them.
Medical audit paves the way to:
- Find if the organizational policies are current and effective
- Educate healthcare providers on proper documentation guidelines
- Review the quality of care offered to patients
- Optimize healthcare revenue cycle management
- Defend against health plan denials
- Check with appropriate revenue is captured
All About Internal & External Audits
As we know, the internal medical audit is done by practice staff or with the help of an internal compliance officer; an external audit may be conducted with the help of a third-party medical audit service provider. Even if you have a good medical billing company managing your entire revenue cycle, conducting internal and external audits regularly is very crucial. Some of the experienced medical billing outsourcing companies like CapMinds also provide clinical records and documentation audits as part of their services.
The Real Purpose of Medical Billing Audits
A medical coding compliance audit examines medical records to determine coding accuracy, policies, and procedures. A billing audit is much more extensive as it covers all processes in the medical billing cycle – from patient eligibility verification, the capture of patient demographic data, the medical coding, claims submission, payment posting, accounts receivable, and denial management practices. A medical billing audit evaluates medical billing records to identify areas requiring improvement or special attention.
Medical billing audits can uncover many issues:
- Errors in provider documentation
- Wrong or inappropriate codes, use of deleted codes, and frequency of such errors
- Under coding, overcoming, unbundling and modifier use concerns
- Problems in payer reimbursement
- Areas of non-compliance to payer rules
- Fraudulent billing practices, whether intended or unintended
- Errors in claim scrubber software utilized by the medical practice
A medical billing audit can protect your practice against fraudulent billing and claims submission which can lead to heavy Medicare penalties. It also identifies and addresses areas of risk that may attract scrutiny by a Recovery Audit Contractor (RAC).
Steps In A Medical Billing Audit
Knowing how the medical billing audit process works is important so that your office can be prepared for it. Keep in mind that there is no “one size fits all” when it comes to reviewing a practice’s medical billing and coding. However, there are four basic steps involved in the billing audit process:
Determine the Scope of the Audit
There are various options such as a random audit, a comprehensive audit, and a hybrid audit. In a random audit, both large and small claims are selected at random based on their dollar amounts. A comprehensive audit covers a close inspection of audited claims with a focus on claiming refunds.
The hybrid audit blends both the random and comprehensive audit approaches by evaluating samples of all types of claims to detect any gaps. When you determine the scope of the audit and the number of claims to review, you also need to ensure that you have the resources and support (internal/ external) to implement the process successfully.
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Identify a Period to Pull Samples to Audit
The number of claims in a sample should be based on the number of physicians in your practice. You also need to set the appropriate time to pull the samples to audits – such as a week, a month, a quarter, or an entire financial year.
Pinpoint Areas of Concern
The next step is examining medical billing reports to identify any areas of risk or concerning trends. Reports are checked against past performances month-to-month or year-to-year. CPT code usage by providers and billing staff are analyzed to see if they are appropriately coding client encounters and if their coding patterns differ among themselves and from a general industry average.
The medical billing audit uses a benchmarking process to accomplish these tasks. Examining billing reports will determine if patient encounters are coded correctly and billing practices are in order, and how CPT codes are being reimbursed. Use spreadsheet software to track data and organize the findings in a report.
Take Corrective Action
Once the audit identifies irregularities, the practice can take corrective action. This includes developing strategies to improve billing processes and procedures, provide additional staff training, and better processes for revenue cycle management while implementing quality assurance protocols.
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